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FICATION NUMBER (TIN) PAYEE NAME (if different): FEDERAL TAXPAYER IDENTIFICATION NUMBER (TIN) SERVICE PROVIDER CERTIFICATION I authorize the above specified payee agency to submit bills to the Department of Human Services on my behalf and designate the payee specified above to receive payment for services that I delivered to persons in a Medicaid Home and CommunityBased Services Waiver for individuals with developmental disabilities. The time period for this authorization is from through . NO.

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